Taiwan's Medical Brain Drain
Where Have All the Doctors Gone?
With modest compensation on home shores, more and more Taiwanese physicians are opting for lucrative careers in China's high-end hospitals, leaving Taiwan with a looming crisis.
Where Have All the Doctors Gone?By Whitney Huang
From CommonWealth Magazine (vol. 528 )
This is a story you can't afford to ignore.
Its main protagonists are physicians. And the 23.4 million residents in Taiwan are the supporting actors who can't do without the leading characters. The title of the story is: "The Hospital Emigrates to China."
The manpower shortage in the medical profession is a widely known phenomenon: as many as 66 percent of Taiwan's 368 towns and villages don't have a specialist for emergency medicine, 47 percent don't have a surgeon, 43 percent lack a gynecologist and 36 percent are without a pediatrician.
And that's not all. One in four physicians practices cosmetic surgery or other forms of aesthetic medicine. A report entitled "A General Health Check for the National Health Insurance Program" by Control Yuan member Huang Huang-hsiung et al. found that every year Taiwan faces a severe lack of doctors in the four major specialties: internal medicine, surgery, obstetrics and gynecology, and pediatrics. Surgical medicine registers an annual shortage of 37 percent, followed by Ob-Gyn with 31 percent.
But what few people know is that more than 100 seasoned specialists in surgery and Ob-Gyn have left their Taiwanese hospital jobs to work in China on long-term contracts or clandestinely sneak away over the weekend. Could that be the proverbial straw that breaks the back of Taiwan's medical care system?
CommonWealth Magazine tracked the whereabouts of Taiwan's migrant physicians, visiting numerous hospitals and clinics in Beijing and Shanghai to draw back the curtains on this exodus of the island's medical profession.
Scene 1: A Regional Hospital, Taipei
Medical Specialists Gone Missing
An otolaryngologist at a district hospital in northern Taiwan wanted to refer a patient with severe strabismus to a retired eye doctor, who is an authority in his field and works part time at a local clinic. Yet despite repeated attempts, he was not able to reach the ophthalmologist.
Only later did he find out that the said doctor worked most of the time in China, so he could only get an appointment for his referral patient during the doctor's short returns to Taiwan.
"I really feel sorry for Taiwanese patients, because they don't know their doctors have already run away to China," the Taipei-based physician says, both surprised and a little distressed.
On direct cross-strait flights to Chinese metropolises such as Beijing, Shanghai and Xiamen, but also more far-flung places like Lanzhou and Urumqi, the heroes in white cloaks have joined earlier groups of migrating professionals – entrepreneurs, managers, accountants, and lawyers.
In late June, when Taiwan and China signed a bilateral agreement on trade in services, investment in hospitals in China was opened up, including bilateral joint ventures and fully Taiwanese-owned healthcare facilities. Former Taiwanese health minister Yang Chih-liang was a bit alarmed when reading this piece of news. He told CommonWealth Magazine that Taiwan's government needs to be prepared for Chinese hospitals to poach Taiwanese doctors with high salaries. He warned that Taiwan's already understaffed healthcare system will face a further drain of medical personnel.
In fact, Taiwanese physicians began to migrate to China some time ago. Due to the severe shortage of high-caliber surgeons on both sides of the Strait, quite a number of Taiwanese surgeons are regularly performing surgeries in Chinese hospitals on weekends.
They are known as "weekend flying scalpels."
Dr. A, a fortysomething surgeon who works at a Taiwanese district hospital and prefers to remain anonymous, is one of them.
A few years ago Dr. A was "finally" recruited by an international headhunting agency on behalf of a Chinese hospital. At the time Dr. A was not surprised at all, because it is a well-known fact in the world of surgical medicine that headhunters are keen to poach Taiwanese doctors.
Every Friday morning Dr. A takes a flight to China to see his patients and conduct a string of surgeries on Saturday and Sunday. On Sunday night or early Monday morning he flies back to Taiwan and directly goes to work at the hospital.
"According to insider slang in the medical community, we're called 'flying scalpels,'" remarks Dr. A, who claims to personally know of more than 100 such weekend commuter surgeons from Taiwan.
Given that Taiwan has more than 6,400 surgeons, the loss of 100 to China does not seem like a grave threat. But in reality their exodus erodes the base of Taiwan's medical care, because they belong to the middle-aged generation of high achievers.
Most of the "flying scalpels" are around forty and come from different surgery-related fields including orthopedics, general surgery, cardiac surgery, neurosurgery, and obstetrics. While they are not necessarily luminaries within their field, "the medical profession knows that these people are really, really good at performing surgeries," explains Dr. A.
Some surgeons have not stopped at moonlighting in China on the weekends, but instead have completely given up their jobs in Taiwan to embark on new careers in China.
Scene 2: An Upscale Hospital, Shanghai
President Plays Phone Operator
The Taiwanese-funded Shanghai Ruidong Hospital is located in Shanghai's glitzy Pudong District. On the glass doors leading to its foyer are stuck a plethora of national flags from Britain, France, Japan, South Korea, the United States and other countries. Upon entering, visitors are greeted by a signboard that welcomes them in the Korean language.
During a one-hour interview with CommonWealth Magazine, the cell phone of hospital president Jene-John Fu rang several times. Each time he greeted callers, in standard Mandarin, with a polite "Ruidong Hospital, may I help you?"
In Taiwan you won't find a hospital where the president personally does telephone duty. When a call is not answered by the operator, service agents or other frontline personnel at Ruidong Hospital, it is automatically forwarded to Fu's cell phone. It has happened that Fu had to take a patient's call at 2 o'clock in the morning.
Fu formerly served as vice president of Cheng Hsin Hospital and head of thoracic surgery. Five years ago, Victor Chang, the CEO of the Landseed International Medical Group, encouraged him to turn his medical "profession" into a medical "business." Fu decided to try his luck in China and accepted Chang's offer to serve as the CEO of the Shanghai Landseed International Hospital, the first Taiwanese-funded hospital in China.
At age 63, Fu looks back on a 30-year career in medicine. He is positive about the prospects of China's health care market. Since Taiwanese physicians have good English language and medical skills, they can attract foreigners who travel or live in China. The added bonus of treating foreign patients is that commercial or foreign health insurance policies usually pay twice or thrice as much for surgeries as Taiwan's National Health Insurance (NHI).
"It's best to make your move sooner rather than later. If you don't take the first step, there won't be a second step," Fu enthuses.
Like surgery, Ob-Gyn is one of the four major "hollowed out" fields of medicine that too few Taiwanese physicians are pursuing. It is also one of the principal beneficiaries of the brain drain to China.
Scene 3: A Maternity Hospital, Beijing
20 Times the Compensation
It is a stifling hot summer day in Beijing in July. The interior of Beijing Baodao Healthcare Maternity Hospital on the third ring road in Haidian District resembles a five-star hotel.
The first Taiwanese-Chinese hospital joint venture since the signing of the Economic Cooperation Framework Agreement (ECFA) two years ago offers high-end obstetric and gynecological services. A delivery at the hospital, for instance, can cost between 58,800 renminbi and 168,800 renminbi (about NT$840,000), roughly ten to twenty times more than what Taiwan's national health insurance pays in physician fees for a childbirth.
Within the front doors of the hospital, soft music greets the visitor. Decorated in tones of white with a six-meter ceiling and a cream-white marble floor, the foyer is flooded with golden light from lamps suspended from the ceiling and mounted on the walls.
On one of the walls of the foyer, a large LCD screen keeps showing a promotional video touting more than a dozen "Taiwanese experts" on staff.
Yu Ken-jen, former head of Ob-Gyn at Kaohsiung Veterans General Hospital, serves as hospital president. His two deputies also hail from Taiwan: Chiang Li-mong, former head of Ob-Gyn at the Heping Fuyou Branch of Taipei City Hospital, and Lin Chin-hung, a gynecologist from the Hualian Tzu Chi Medical Center.
Quite a number of women's medicine specialists from Taiwan travel here to give regular consultation services, including Professor Chang Sheng-ping, who gained fame as "the father of Taiwanese test tube babies" and now is on call at the hospital for five days in a row every month. Female cancer expert C.J. Tseng, vice president of National Sun Yat-sen University Hospital, heads a group of eight gynecologists from the hospital who rotate for a four-day consultation duty in Beijing every two weeks.
Yu and Chiang, whose medical careers span 30 years, both retired early in Taiwan. Their departure hit Taiwan's already troubled Ob-Gyn field like a bombshell. Both drew criticism from professional associations for their decision to work in China.
"I've come here to put to good use the passion I still have. In China the concept of patient-centered healthcare is little known. We have brought over our good experiences," declares Yu. Like most other Taiwanese physicians who are working in China, Yu keeps a low profile and does not brag about his new career.
But why are these veteran doctors ready to risk peer criticism? Why are they willing to go to unfamiliar cities, work at unfamiliar hospitals and treat unfamiliar patients?
Much like Taiwanese companies who look to China for opportunities to expand business when they face bottlenecks at home, Taiwanese doctors and nurses, increasingly suffering from the long-term distortions of Taiwan's health care system, are feeling themselves "pushed toward China."
Exhaustion, Frustration Drive Away Physicians
In Taiwan, hospitals have turned into sweat shops. During consultation hours hospitals are crowded like farmers' markets and doctors are forced to see an endless row of patients without even finding time to take a break for a proper meal. Typically, salaried doctors can only grab a bite when there is an unexpected lull in appointments.
In his book The Collapse of Medical Care, surgeon Yu-Chih Liu notes that the number of practicing physicians increased by 63 percent between 1995 and 2011, while the number of consultations increased by 86 percent and the total number of days spent in hospital by patients increased by 202 percent. The growth in physicians lags far behind the growth in medical care needs. As a result, their workload continues to increase, while the consultation time that can be awarded to each individual patient continues to shrink.
At the same time salary growth for medical doctors lags behind other sectors of the economy. Council of Labor Affairs statistics show that the average salary has shrunk over the years, only recently recovering to the level of ten years ago.
In comparison, the salaries and benefits offered by Chinese hospitals are very attractive.
Typically, salaries are 20 percent to 50 percent higher than in Taiwan, but it is not uncommon for physicians to double their original salary when moving to China.
Taiwan's National Health Insurance system, which gives patients a full range of benefits for little money, also leaves many physicians dissatisfied with their earnings, and is one of the main forces driving them to the greener pastures of China. For many years the medical profession has complained about inadequate NHI compensation fees, but nothing has been done to solve the problem. Even doctors who put vocation before income are in a severe dilemma, because they find it difficult to reconcile their professional ideals with the reality of medical care.
Sitting in his Beijing office, the 59-year-old Chiang reflects on his decision to work in China. Although the veteran doctor sympathizes with Taiwan's China-critical Democratic Progressive Party, he eventually still opted for a new career in China.
During his past career in Taiwan, he constantly had to work extremely long hours due to an excessive workload. It was not out of the ordinary for him to start his evening consultations at 5:30 p.m. and see out the last patient at 2:30 the next morning.
Heaving a heavy sigh, Chiang notes that doctors are often willing to sacrifice their spare time to give patients a few more minutes of consultation time. But hospitals, which have to take into account business performance, do not necessarily welcome such an approach.
In Beijing, the Baodao Healthcare Maternity Hospital has adopted a prior appointment system and requires all physicians to schedule at least 20 minutes for each consultation. In the morning hours Chiang only needs to see four to five patients, which means he can make in-depth diagnoses.
"I feel I can do my patients better justice, and I have a greater sense of achievement," states Chiang quite emotionally.
Hospital vice president Lin, 47, has a grave expression on his face as he recounts why he left Taiwan. "Taiwan's medical care environment is boiling frogs in warm water (committing slow suicide). Physicians enjoy social status, but are prone to exhaustion and exasperation."
In Taiwan Lin worked as an Ob-Gyn surgeon. Since the hospital lacked resident doctors, he often had no other choice but to enter the operating room on tenterhooks, performing C-sections with the assistance of inexperienced interns. The maternity wards also lacked experienced resident physicians and nurses to look after the women post-partum. So if a C-section took place late at night, he was forced to stay at the hospital after the procedure, just in case there was an emergency.
"Physicians have to bear greater medical risks, and that creates a lot of pressure," Lin relates. Taiwanese doctors, it seems, are constantly walking a tightrope.
He frankly admits that Baodao Healthcare Maternity Hospital has received numerous applications from medical students who are about to graduate from the National Taiwan University College of Medicine and Kaohsiung Medical University for resident physician positions in Beijing. The fact that now even medical school graduates are eager to leave for China, makes Lin worry about the future of Taiwan's health care system.
On top of that, more and more pharmaceutical companies are deciding not to export new medicines or medical materials to Taiwan, because NHI compensation fees are too low. Experienced doctors can't help worrying that in the future some doctors might tell their Taiwanese patients to come to China for scheduled surgeries.
World's Third-largest Healthcare Market
The deterioration of working conditions in Taiwan's healthcare system provides the push, and China's exploding demand for healthcare services gives the pull.
The latest OECD Health Data report, released in July 2013 by the Europe-based Organization of Economic Cooperation and Development, states that Chinese healthcare expenditure grew at an annual rate more than 9 percent in the decade between 1998 and 2008. China has now become the world's third largest healthcare market.
At the same time China has been aggressively reforming its health system. Under the 12th five-year plan, public hospitals are required to restructure completely. The number of privately run or privately owned hospitals is also supposed to jump tenfold in the coming twelve years.
The rapidly expanding private hospitals do not shy away from spending large sums to attract medical talent to staff their health services for China's rich.
The easiest and fastest way for China to make up the current shortage in medical specialists is to go headhunting in Taiwan. "They have a plan to headhunt 1,000 people," Tseng says.
A Shanghai-based headhunting agency is known to have established a database by contacting individual physicians one by one at prestigious hospitals such as National Taiwan University Hospital, Mackay Memorial Hospital and Taipei Veterans General Hospital. As soon as there is a matching job opportunity, the agency launches a full-fledged effort to recruit individuals from this talent pool.
A neurosurgeon in a leading position, who did not want to be named, observes that the current exodus of physicians has not jeopardized Taiwanese residents' adequate supply of medical services yet, but the real fallout will be felt a few years down the road. When excellent doctors leave to work in China, they won't impart their professional experience on the younger generations of physicians. Instead, they will export their skills and knowledge to China. This is what Taiwan has most to lose, the neurosurgeon warns.
What can Taiwan do to retain its medical elite, talent whose costly education was funded by devoted parents and the state? All of us, both the government and the public, need to face the fact that the NHI compensation system is unreasonable and that physicians have to put up with worsening working conditions. What it takes is the resolve to make decisions and solve these problems.
Plugging the Brain Drain
When Chen Wei-ming, the 51-year-old head of the department of orthopedics and traumatology at Taipei Veterans General Hospital, returns home every night well after dark, he is so exhausted that his voice is raspy. He counts among the prime targets of Chinese hospital headhunters and is so well known there that virtually every week Chinese patients come to see him in Taiwan to schedule a surgery.
Recently he implanted an artificial knee in a patient from Shanghai. The surgery cost just one fourth of what the patient would have had to pay in China and spared him the obligatory "red envelope" gratuity that renowned Chinese doctors commonly expect. The patient was so surprised that he published an essay in the Chinese media hailing healthcare in Taiwan.
Chen does not want to leave Taiwan, but he harbors strong feelings of resentment. "Do you know what's tragic in Taiwan? Doctors have no choice but to bathe their own faces with their tears. The nation is mistreating its talent," he complains. Chen believes that the government bears the greatest responsibility for the ills of the healthcare system, because payments from the NHI are too low.
Investors, hospital operators and deserting physicians reap the greatest benefits from the medical brain drain to China. The victims are both the physicians who stay behind in Taiwan, treating spiraling numbers of patients, and Taiwanese patients themselves.
Upon repeated inquiries the Ministry of Health and Welfare, formed only in mid-July through the upgrading of the Department of Health as result of wide-ranging cabinet reforms, proposed a number of improvement measures. The ministry plans, for instance, to allocate an additional NT$5 billion to subsidize salaries for resident physicians in the five most understaffed medical specialties: internal medicine, surgery, pediatrics, Ob-Gyn, and emergency medicine.
Lee Wei-chiang, head of the medical affairs section at the Ministry of Health and Welfare, tells CommonWealth Magazine that as part of initial reforms the ministry has introduced revisions to the Medical Malpractice Resolution and Compensation Act. The draft revisions, which have already been submitted to the legislature, aim to decriminalize or ameliorate criminal liability for medical errors and malpractice.
This will be the first small step toward reform, Lee notes.
In order to guarantee the welfare of Taiwan's population of 23.4 million and to prevent a scenario in which physicians genuinely can't be found in Taiwan, the island's healthcare environment and NHI system must change – that much is sure.
Not sometime in the future, but now.
Translated from the Chinese by Susanne Ganz